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Oda A, Oue K, Oda Y, Taguchi S, Takahashi T, Mukai A, Doi M, Shimizu Y, Irifune M, Yoshida M. Difficult intubation and postoperative aspiration pneumonia associated with Moebius syndrome: a case report. BMC Anesthesiol 2022; 22:316. [PMID: 36221060 PMCID: PMC9552434 DOI: 10.1186/s12871-022-01859-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/05/2022] [Indexed: 12/05/2022] Open
Abstract
Background Moebius syndrome is a rare congenital disorder characterized by non-progressive palsy of the abducens (VI) and facial (VII) cranial nerves. Its common features include dysfunctions associated with other cranial nerves, orofacial abnormalities, skeletal muscle hypotonia, and other systemic disorders of differing severities. There are several concerns in the perioperative management of patients with Moebius syndrome. Case presentation We present a report on the management of general anesthesia of a 14-year-old male patient with Moebius syndrome who was scheduled for mandibular cystectomy. The patient was diagnosed with Moebius syndrome at the age of 7 years based on his clinical manifestations of nerve palsy since birth and cranial nerve palsy of the trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), and sublingual nerves (XII). The patient’s oral morphological abnormalities made intubation difficult. He also experienced dysphagia and aspiration pneumonia on a daily basis. Oral secretions were frequently suctioned postoperatively. However, after discharge, the patient developed aspiration pneumonia and was readmitted to the hospital. Conclusions The main problem arising when administering general anesthesia to patients with this syndrome is difficult airway management. The oral abnormalities in these patients, such as small jaw and extreme dental stenosis, make mask ventilation and intubation difficult. Furthermore, this syndrome often involves respiratory impairment and dysphagia due to cerebral nerve palsy, so there is a high risk of postoperative respiratory complications. Since multiple organs are affected in patients with Moebius syndrome, appropriate perioperative management strategies must be prepared for these patients.
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Affiliation(s)
- Aya Oda
- Department of Dental Anesthesiology, Division of Oral and Maxillofacial Surgery and Oral Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Hiroshima, 734-8551, Japan
| | - Kana Oue
- Department of Dental Anesthesiology, Division of Oral and Maxillofacial Surgery and Oral Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Hiroshima, 734-8551, Japan.
| | - Yuki Oda
- Department of Special Care Dentistry, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Hiroshima, 734-8551, Japan
| | - Shima Taguchi
- Department of Anesthesiology and Critical Care, Hiroshima University, Hiroshima, Japan
| | - Tamayo Takahashi
- Department of Dental Anesthesiology, Division of Oral and Maxillofacial Surgery and Oral Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Hiroshima, 734-8551, Japan
| | - Akari Mukai
- Department of Dental Anesthesiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Mitsuru Doi
- Department of Dental Anesthesiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshitaka Shimizu
- Department of Dental Anesthesiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Irifune
- Department of Dental Anesthesiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Mitsuhiro Yoshida
- Department of Dental Anesthesiology, Division of Oral and Maxillofacial Surgery and Oral Medicine, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Hiroshima, 734-8551, Japan
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Abstract
BACKGROUND Mobius syndrome is a rare syndrome that is known to be associated with a variety of orthopaedic conditions including scoliosis, clubfoot, transverse limb deficiencies, Poland syndrome, and a myriad of hand conditions. To date, no large series exist to characterize the orthopaedic manifestations of Mobius syndrome. METHODS Medical records at a single tertiary pediatric institution were reviewed for all patients diagnosed with Mobius syndrome from January 1, 1980 to December 31, 2015. Records and radiographs were reviewed for associated orthopaedic conditions and their management. RESULTS In total, 44 patients with Mobius syndrome were identified. Age at presentation ranged from 6 days to 14 years. When compared with the general population, patients with Mobius syndrome had an increased incidence of clubfoot (41%), Poland syndrome (20%), and scoliosis (14%). Clubfoot treated both before and after the institution of Ponseti casting had a high rate of requiring posteromedial release, with a significant rate of subsequent revision. Hip dysplasia was noted in 1 patient and required surgical correction. Other associated syndromes included arthrogryposis, Pierre Robin syndrome, and chromosome 10 defect. CONCLUSIONS Mobius syndrome is accompanied by an increased rate of several orthopaedic problems; most notably clubfoot, scoliosis, and upper extremity differences that often require surgical treatment. The management of clubfoot in the setting of Mobius syndrome often requires surgical intervention due to failure of casting, and seems to have a higher rate of need for revision. Early involvement of orthopaedists in the care of patients with Mobius syndrome is often necessary. Orthopaedist should counsel families that treatment may be more complex than that of idiopathic disease. LEVEL OF EVIDENCE Level IV-case series.
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An exome sequencing study of Moebius syndrome including atypical cases reveals an individual with CFEOM3A and a TUBB3 mutation. Cold Spring Harb Mol Case Stud 2017; 3:a000984. [PMID: 28299356 PMCID: PMC5334472 DOI: 10.1101/mcs.a000984] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Moebius syndrome is characterized by congenital unilateral or bilateral facial and abducens nerve palsies (sixth and seventh cranial nerves) causing facial weakness, feeding difficulties, and restricted ocular movements. Abnormalities of the chest wall such as Poland anomaly and variable limb defects are frequently associated with this syndrome. Most cases are isolated; however, rare families with autosomal dominant transmission with incomplete penetrance and variable expressivity have been described. The genetic basis of this condition remains unknown. In a cohort study of nine individuals suspected to have Moebius syndrome (six typical, three atypical), we performed whole-exome sequencing to try to identify a commonly mutated gene. Although no such gene was identified and we did not find mutations in PLXND1 and REV3L, we found a de novo heterozygous mutation, p.E410K, in the gene encoding tubulin beta 3 class III (TUBB3), in an individual with atypical Moebius syndrome. This individual was diagnosed with near-complete ophthalmoplegia, agenesis of the corpus callosum, and absence of the septum pellucidum. No substantial limb abnormalities were noted. Mutations in TUBB3 have been associated with complex cortical dysplasia and other brain malformations and congenital fibrosis of extraocular muscles type 3A (CFEOM3A). Our report highlights the overlap of genetic etiology and clinical differences between CFEOM and Moebius syndrome and describes our approach to identifying candidate genes for typical and atypical Moebius syndrome.
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Pedersen LK, Maimburg RD, Hertz JM, Gjørup H, Pedersen TK, Møller-Madsen B, Østergaard JR. Moebius sequence -a multidisciplinary clinical approach. Orphanet J Rare Dis 2017; 12:4. [PMID: 28061881 PMCID: PMC5217236 DOI: 10.1186/s13023-016-0559-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/22/2016] [Indexed: 01/31/2023] Open
Abstract
Background Moebius Sequence (MS) is a rare disorder defined by bilateral congenital paralysis of the abducens and facial nerves in combination with various odontological, craniofacial, ophthalmological and orthopaedic conditions. The aetiology is still unknown; but both genetic (de novo mutations) and vascular events in utero are reported. The purpose of present study was through a multidisciplinary clinical approach to examine children diagnosed with Moebius-like symptoms. Ten children underwent odontological, ophthalmological, obstetric, paediatric, orthopaedic, genetic, radiological and photographical evaluation. Five patients maintained the diagnosis of MS according to the diagnostic criteria. Results All five patients had bilateral facial and abducens paralysis confirmed by ophthalmological examination. Three of five had normal brain MR imaging. Two had missing facial nerves and one had missing abducens nerves. The Strengths and Difficulties Questionnaire (SDQ) showed normal scores in three of five patients. Interestingly, two of five children were born to mothers with uterine abnormalities (unicornuate/bicornuate uterus). In the odontological examination three of five showed enamel hypomineralisation. All five had abnormal orofacial motor function and maxillary prognathism. Two patients had adactyly, syndactyly and brachydactyly. None of the five patients had Poland anomaly, hip dislocation or dysplasia but all had a mild degree of scoliosis. We observed congenital club-feet, calcaneovalgus deformities, macrodactyly of one or more toes or curly toes. Pedobarography showed plantar pressures within normal ranges. Conclusions Adherence to standard diagnostic criteria is central in the diagnosis of MS. An accurate diagnosis is the basis for correct discussion of other relevant concomitant symptoms of MS, genetic testing and evaluation of prognosis. The multidisciplinary approach and adherence to diagnostic criteria taken in present study increases the knowledge on the relationship between genotype, phenotype and symptomatology of MS.
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Affiliation(s)
- Line Kjeldgaard Pedersen
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark. .,Department of Childrens Orthopaedics, Aarhus University Hospital, Aarhus, Denmark.
| | - Rikke Damkjær Maimburg
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Gynaecology-Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Michael Hertz
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Hans Gjørup
- Department of Maxillofacial Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Klit Pedersen
- Department of Maxillofacial Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthodontics, Aarhus University, Aarhus, Denmark
| | - Bjarne Møller-Madsen
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Childrens Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
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Prenatal exposure to environmental factors and congenital limb defects. ACTA ACUST UNITED AC 2016; 108:243-273. [DOI: 10.1002/bdrc.21140] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 09/29/2016] [Indexed: 12/26/2022]
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Shawky RM, Gamal R, Abdelsattar Mohammad S. Moebius syndrome with macular hyperpigmentation, skeletal anomalies, and hypoplasia of pectoralis major muscle in an Egyptian child. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2015. [DOI: 10.1016/j.ejmhg.2014.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Kadakia S, Helman SN, Schwedhelm T, Saman M, Azizzadeh B. Examining the genetics of congenital facial paralysis--a closer look at Moebius syndrome. Oral Maxillofac Surg 2015; 19:109-16. [PMID: 25663568 DOI: 10.1007/s10006-015-0485-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 01/26/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The molecular underpinnings of Moebius syndrome (MBS) are diverse. This article provides a comprehensive summation of the genetic and etiologic literature underlying this disorder. Elucidating the genetic causes of the disorder can aid in earlier detection and treatment planning. DESIGN Articles from 1880-2013 were selected and reviewed by six researchers to understand all of the molecular theories and chronicity of advancements in the literature. RESULTS Mutations in the MBS1, MBS2, and MBS3 gene loci all have contributed to the development of MBS through various pathways. HOX family genes coding for homeobox domains, also, have been implicated in the abnormal development of the human brain. These are among the numerous genes that have been linked to the development of MBS. CONCLUSION Our study codified nascent findings of the molecular determinants of MBS. These findings add to a growing database of MBS-associated mutations and can be used to diagnose MBS and clarify pathogenesis.
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Affiliation(s)
- Sameep Kadakia
- Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary-Mount Sinai Health System, 310 East 14th Street, 6th Floor, New York, NY, 10009, USA,
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Furuta M, Mihara M, Kimura Y, Okuno T, Takahashi MP, Mochizuki H. [A case of Möbius syndrome with congenital facial palsy and supranuclear oculomotor palsy]. Rinsho Shinkeigaku 2015; 55:233-237. [PMID: 25904251 DOI: 10.5692/clinicalneurol.55.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
An 18-year-old man with congenital weakness in the facial and mastication muscles was referred to us. His facial senses were intact; however, the bilateral massetter and facial muscles were extremely weak and atrophic. He presented lagophthalmos and had difficulty in closing his mouth. The voluntary movements of his left eye, such as abduction, adduction, and elevation, were partially impaired, without the impairment of the Bell phenomenon. Nerve conduction studies of the facial nerves revealed normal distal latencies for bilateral orbicularis oculi. Blink reflexes were not evoked on both sides. Needle electromyography showed a chronic neurogenic change in the tongue. A biopsy of the biceps brachii and skin did not show abnormality. We diagnosed his condition as Möbius syndrome with congenital facial palsy and supranuclear oculomotor palsy. Möbius syndrome, which manifests itself as congenital and non-progressing facial and abducens palsy, is associated with many clinical symptoms and is probably heterogenous nosological entity. Although several cases of Möbius syndrome with supranuclear binocular elevation palsy were previously known, this is the first case of Möbius syndrome presenting supranuclear monocular elevation palsy.
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Affiliation(s)
- Mitsuru Furuta
- Department of Neurology, Osaka University Graduate School of Medicine
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MacKinnon S, Oystreck DT, Andrews C, Chan WM, Hunter DG, Engle EC. Diagnostic distinctions and genetic analysis of patients diagnosed with moebius syndrome. Ophthalmology 2014; 121:1461-8. [PMID: 24612975 DOI: 10.1016/j.ophtha.2014.01.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/02/2014] [Accepted: 01/03/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To improve diagnostic assessment in Moebius syndrome by (1) creating more selective diagnostic subgroups and (2) conducting genetic evaluation in a large patient cohort. DESIGN Prospective, observational study. PARTICIPANTS Attendees of 3 consecutive Moebius syndrome conferences held in the United States, with a prior diagnosis of Moebius syndrome, were invited to participate. METHODS Participants underwent standardized ophthalmologic examination for Moebius syndrome minimum diagnostic criteria (MDC) (congenital, nonprogressive facial palsy, and abduction deficit) and genetic testing for HOXA1, HOXB1, and TUBB3 mutations. MAIN OUTCOME MEASURES The number of patients meeting MDC and the number of patients with confirmed genetic mutation. RESULTS A total of 112 participants from 107 families enrolled. Nineteen percent of participants (21/112) did not meet accepted MDC for Moebius syndrome because they had abduction deficits without facial palsy or facial palsy with full ocular motility. All 5 families with 2 affected individuals had at least 1 family member in this category, including 2 siblings with comitant strabismus who harbored a HOXB1 mutation. Four unrelated participants, also not meeting MDC, had large-angle exotropia, vertical gaze deficiency, and ptosis consistent with congenital fibrosis of the extraocular muscles type 3 (CFEOM3); 1 patient harbored a novel TUBB3 mutation, and 3 patients harbored previously reported de novo TUBB3 mutations. Three percent of participants (3/112) met MDC but also had restricted vertical gaze. The remaining 88 participants (79%) met MDC and had full vertical gaze. This group had relatively homogeneous findings, and none had a family history of Moebius syndrome. Two previously undescribed phenomena were observed in this category: (1) volitional Bell's phenomenon and (2) intorsion with fixation. CONCLUSIONS Although the genetic contributors to classic Moebius syndrome remain elusive, accuracy in clinical evaluation will properly subdivide patients to facilitate genetic testing as new candidate genes are identified. Failure to test ocular motility may lead to misdiagnosis of Moebius syndrome, especially in patients who have facial palsy with full ductions. Patients with exotropia, vertical gaze limitation, and ptosis do not have classic Moebius syndrome and may have TUBB3 mutations associated with CFEOM3. To optimize genetic analysis, we propose adding "full vertical motility" to the MDC for Moebius syndrome.
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Affiliation(s)
- Sarah MacKinnon
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Darren T Oystreck
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Ophthalmology, Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Caroline Andrews
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts; Howard Hughes Medical Institute, Chevy Chase, Maryland
| | - Wai-Man Chan
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts; Howard Hughes Medical Institute, Chevy Chase, Maryland
| | - David G Hunter
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
| | - Elizabeth C Engle
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; F. B. Kirby Neurobiology Center, Boston Children's Hospital, Boston, Massachusetts; Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Department of Neurology, Harvard Medical School, Boston, Massachusetts; Howard Hughes Medical Institute, Chevy Chase, Maryland.
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Flores A, Ross JR, Tullius TG, Levin GS. A unique variant of Poland-Mobius syndrome with dextrocardia and a 3q23 gain. J Perinatol 2013; 33:572-3. [PMID: 23803678 DOI: 10.1038/jp.2012.92] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The combined Poland and Mobius syndrome occurs rarely and with a wide range of features. There is no consensus on the etiology of this syndrome; familial, sporadic cases and likely environmental insult cases have been reported. This sporadic case represents a unique variant in the spectrum of this syndrome.
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Affiliation(s)
- A Flores
- Division of Neonatology, Department of Pediatrics, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, TX 79905, USA.
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Chou IC, Lin WD, Wang CH, Chang YT, Chin ZN, Tsai CH, Tsai FJ. Möbius syndrome in a male with XX/XY mosaicism. Biomedicine (Taipei) 2013. [DOI: 10.1016/j.biomed.2013.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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